Emergency Contact
Eppley Recreation Center ∙ 4128 Valley Drive, College Park, MD 20742 ∙ www.terpquest.umd.edu
AUTHORIZED PICK-UP/ EMERGENCY CONTACT FORM due by May 31, 2017 Emergency Contact / Camper Pick-up:
Parents/guardians listed on the first page of this document DO NOT need to be listed below. If you need to have anyone other than a parent/guardian pick-up your child, a completed and signed Pick-up/Release Authorization Form must be submitted to TERP quest PRIOR TO the camper’s departure from camp. Sorry, but for everyone’s safety WE CANNOT accept phone messages or notes provided by the pick-up person at the pick-up point. For your child’s protection we cannot make any exceptions to this policy. Please, only one camper per form. Please complete additional forms for additional campers.
All names listed on the Camper Profile Form and the Authorized Pick-Up/Emergency Contact Form below should also be added to your Online Account as Authorized Pick-up persons. Failure to update your records may result in a delay in the release of your camper to you.
Authorized Person(s) for Pick Up: As legal, custodial parent/guardian of (camper’s full name) ___________________________________, I (parent/guardian name), _____________________________________, give the following individuals permission to pick-up my child: PICK-UP AUTHORIZED PERSON
EMERGENCY CONTACT?
1. _____________________________________________________
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Full Name / Emergency Phone (123-123-1234)
2. _____________________________________________________ Full Name / Emergency Phone (123-123-1234)
3. _____________________________________________________ Full Name / Emergency Phone (123-123-1234)
4. _____________________________________________________ Full Name / Emergency Phone (123-123-1234)
5. _____________________________________________________ Full Name / Emergency Phone (123-123-1234)
I understand that neither TERP Quest nor any of its representatives can be held responsible for my child once they are under the supervision of the individual listed above. For the safety of the camper, TERP Quest representatives may ask the individual listed above to verify their identity by showing an official picture ID (drivers license, ID card, current passport, etc.) prior to releasing the camper.
Legal Custodial Parent/Guardian Signature: ______________________ Date: ____________
Un-Authorized Person for Pick Up: Please notify Camp in writing if there is someone who should not be allowed to pick-up you child. If a family member is not permitted to pick-up you camper, a certified copy of the court order must be forwarded to the attention of TERP Quest Summer Day Camp attention. The following are legally restricted from picking up my child. A copy of a court order is enclosed:
Name: _______________________________________________________________ Relationship: _______________________________________________________________ Legal Custodial Parent/Guardian Signature: ________________________ Date: __________
AUTHORIZED PICK-UP/ EMERGENCY CONTACT FORM due by May 31, 2017 Emergency Contact / Camper Pick-up:
Parents/guardians listed on the first page of this document DO NOT need to be listed below. If you need to have anyone other than a parent/guardian pick-up your child, a completed and signed Pick-up/Release Authorization Form must be submitted to TERP quest PRIOR TO the camper’s departure from camp. Sorry, but for everyone’s safety WE CANNOT accept phone messages or notes provided by the pick-up person at the pick-up point. For your child’s protection we cannot make any exceptions to this policy. Please, only one camper per form. Please complete additional forms for additional campers.
All names listed on the Camper Profile Form and the Authorized Pick-Up/Emergency Contact Form below should also be added to your Online Account as Authorized Pick-up persons. Failure to update your records may result in a delay in the release of your camper to you.
Authorized Person(s) for Pick Up: As legal, custodial parent/guardian of (camper’s full name) ___________________________________, I (parent/guardian name), _____________________________________, give the following individuals permission to pick-up my child: PICK-UP AUTHORIZED PERSON
EMERGENCY CONTACT?
1. _____________________________________________________
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Full Name / Emergency Phone (123-123-1234)
2. _____________________________________________________ Full Name / Emergency Phone (123-123-1234)
3. _____________________________________________________ Full Name / Emergency Phone (123-123-1234)
4. _____________________________________________________ Full Name / Emergency Phone (123-123-1234)
5. _____________________________________________________ Full Name / Emergency Phone (123-123-1234)
I understand that neither TERP Quest nor any of its representatives can be held responsible for my child once they are under the supervision of the individual listed above. For the safety of the camper, TERP Quest representatives may ask the individual listed above to verify their identity by showing an official picture ID (drivers license, ID card, current passport, etc.) prior to releasing the camper.
Legal Custodial Parent/Guardian Signature: ______________________ Date: ____________
Un-Authorized Person for Pick Up: Please notify Camp in writing if there is someone who should not be allowed to pick-up you child. If a family member is not permitted to pick-up you camper, a certified copy of the court order must be forwarded to the attention of TERP Quest Summer Day Camp attention. The following are legally restricted from picking up my child. A copy of a court order is enclosed:
Name: _______________________________________________________________ Relationship: _______________________________________________________________ Legal Custodial Parent/Guardian Signature: ________________________ Date: __________
